Medical Coverage Policy Page: 1 of 15 Change Summary: Updated Coverage Determination, Coverage Limitations, Background, Medical Terms, References Disclaimer Description Coverage Determination Background Medical Alternatives Provider Claims Codes Medical Terms References Disclaimer Description State and federal law, as well as contract language, including definitions and specific inclusions/ exclusions, take precedence over clinical policy and must be considered first in determining eligibility for coverage. Coverage may also differ for our Medicare and/or Medicaid members based on any applicable Centers for Medicare & Medicaid Services (CMS) coverage statements including National Coverage Determinations (NCD), Local Medical Review Policies (LMRP), and/or Local Coverage Determinations. See the CMS web site at http://www.cms.hhs.gov/. The member's health plan benefits, in effect on the date services are rendered, must be used. Clinical policy is not intended to preempt the judgment of the reviewing Medical Director or dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in rendering the most appropriate care. Identification of selected brand names of devices, tests, and procedures in a Medical Coverage Policy are for reference only and is not an endorsement of any one device, test or procedure over another. Clinical technology is constantly evolving, and we reserve the right to review and update this policy periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any shape or form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Humana Inc. Bone growth stimulation is utilized to promote bone healing in difficult to heal fractures or fusions by applying electrical or ultrasonic current to the fracture/fusion site. Electrical stimulation can be applied either from the outside of the body (noninvasive) or from the inside of the body (invasive). Noninvasive (external) electrical bone growth stimulators are devices worn on the outside of the skin. They utilize treatment coils situated externally around the fracture or fusion site and an external power supply. There are three types of noninvasive electrical bone growth stimulators: Capacitive coupling (CC) devices CC devices use metal electrodes, which are applied to the skin to deliver the current. An example of a CC device includes, but
Page: 2 of 15 may not be limited to the EBI OrthoPak 2 Bone Growth Stimulator. Pulsed electromagnetic field (PEMF) devices PEMF devices use an externally applied coil to deliver the current, which can be pulsed on and off. Examples of PEMF devices include, but may not be limited to the EBI Bone Healing System, the Orthofix Cervical Stim, the Orthofix Physi Stim, the Orthofix Spinal Stim and the SpinalPak II Spinal Fusion Stimulator. Combined magnetic field (CMF) devices CMF devices use an external coil system with a combination of direct and alternating current to produce both static and alternating magnetic fields. Examples of CMF devices include, but may not be limited to the OrthoLogic (OL) 1000 Bone Growth Stimulator and the SpinaLogic Bone Growth Stimulator. The surgically implanted or invasive electrical bone growth stimulators utilize direct current to the nonhealing fracture or bone fusion site. Examples of invasive (implantable) electrical bone growth stimulators include but are not limited to the following: the EBI OsteoGen Bone Growth Stimulator, the OsteoGen Dual Lead Bone Growth Stimulator, the OsteoGen M Bone Growth Stimulator, the SpF PLUS Mini Spinal Fusion Stimulator, the SpF XL IIb Spinal Fusion Stimulator, and the Zimmer Direct Current Bone Growth Stimulator. Ultrasonic fracture healing utilizes a signal generator and a transducer, which when placed over the fracture site on the skin, emits low intensity ultrasound signals that are emitted directly to the fracture. Examples of ultrasonic bone growth stimulators include, but may not be limited to the Exogen 4000+, Exogen 3000, Exogen 2000+, and Exogen 2000 (also known as the SAFHS Model 2000 or the Exogen Pulsed Low Intensity Ultrasound Bone Healing System Model 2000).
Page: 3 of 15 Coverage Determination Noninvasive Electrical Bone Growth Stimulator Humana members may be eligible under the Plan for the use of a noninvasive electrical bone growth stimulator ONLY when the following criteria are met: Non union of long bone* fracture and ALL of the following: The bone is non infected; AND The two portions of the bone involved in the non union are separated by less than 1 centimeter (cm); AND The bone is stable at both ends by means of a cast or fixation; AND When serial radiographs (x rays) have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the noninvasive electrical bone growth stimulator. Serial radiographs must include a minimum of two sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days; OR Failed fusion, where a minimum of six months has elapsed since the last surgery; OR As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion surgery or for those undergoing fusion at more than one level; OR Congenital pseudoarthrosis; OR Risk of delayed or non union of fractures due to the following comorbidities (list may not be all inclusive): Alcoholism Chemotherapy Diabetes Obesity
Page: 4 of 15 Osteoporosis Renal disease Smoking habit Steroid use *Long bones are primarily found in the extremities and are comprised of a shaft (diaphysis) and two ends (epiphysis). Long bones, which are not straight but slightly curved, include the clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpals, metatarsals, and phalanges. Invasive Electrical Bone Growth Stimulator Humana members may be eligible under the Plan for the use of an invasive electrical bone growth stimulator ONLY when the following criteria are met: Non union of long bone* fracture and ALL of the following: The bone is non infected; AND The two portions of the bone involved in the non union are separated by less than 1 cm; AND The bone is stable at both ends by means of a cast or fixation; AND When serial radiographs have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the invasive bone growth stimulator. Serial radiographs must include a minimum of two sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days; OR As an adjunct to spinal fusion surgery for patients at high risk of pseudoarthrosis due to previously failed fusion surgery or for those undergoing fusion at more than one level; OR Risk of delayed or non union of fractures due to the following comorbidities (list
Page: 5 of 15 may not be all inclusive): Alcoholism Chemotherapy Diabetes Obesity Osteoporosis Renal disease Smoking habit Steroid use Ultrasonic Bone Growth Stimulator Humana members may be eligible under the Plan for the use of an ultrasonic (US) bone growth stimulator when the following criteria are met: Fresh*, closed or grade I** open, short oblique or short spiral tibial diaphyseal fractures treated with closed reduction and cast immobilization in skeletally mature patients***; OR Fresh*, closed fractures of the distal radius (Colles fracture) treated with closed reduction and cast immobilization in skeletally mature patients***; OR Fresh* Jones fracture (5 th metatarsal); OR Fresh* fractures of the scaphoid; OR Nonunion of bones other than the skull or vertebrae in skeletally mature patients***, and excluding those that are related to malignancy when: Serial radiographs have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the ultrasonic bone growth stimulator. Serial radiographs must include a minimum of two sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days; AND
Page: 6 of 15 The patient has failed 1 surgery and other medical therapies; OR Risk of delayed or non union of ANY fresh*, closed fractures due to the following comorbidities (list may not be all inclusive): Alcoholism Chemotherapy Diabetes Obesity Osteoporosis Renal disease Smoking habit Steroid use *Fresh is considered 7 days in duration. **Grade I denotes that the skin opening is one centimeter or less and minimal muscle contusion. ***Skeletally mature refers to a system of fused skeletal bones, which occurs when bone growth ceases after puberty; for females, this generally occurs around age 16, and for males, around age 18. Note: This criteria for bone growth stimulators is not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS web site at http://www.cms.hhs.gov for additional information. Coverage Limitations Humana members may NOT be eligible under the Plan for the use of noninvasive or invasive electrical bone growth stimulators for any other indications not listed above. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer reviewed medical literature published in the English language.
Page: 7 of 15 Humana members may NOT be eligible under the Plan for the use of ultrasonic bone growth stimulators for any other indications, which include, but may not be limited to: Fractures in which the gap exceeds 1 cm; OR Fresh fractures in locations other than distal radius, tibial diaphysis, 5 th metatarsal (Jones fracture only) or scaphoid; OR Fresh tibial diaphyseal or tibial and fibular fractures treated with closed reduction and intramedullary nailing and no risk factors for poor or prolonged healing; OR Preoperative use for fractures that require surgical intervention, or internal or external fixation (i.e., use of ultrasonic BGS for fractures in the preoperative period would not be covered); OR Tibial stress fractures. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer reviewed medical literature published in the English language. Humana members may NOT be eligible under the Plan for bone growth stimulators for spondylolysis (pars interarticularis defect) or fractures due to osteoporosis. This technology is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer reviewed medical literature published in the English language. Background You can learn more about fractures and spinal fusions from the following sites:
Page: 8 of 15 American Academy of Orthopaedic Surgeons http://www.aaos.org National Library of Medicine http://www.nlm.nih.gov Medical Alternatives Provider Claims Codes To make the best health decision for your individual needs, consult your physician. All provider claims codes surrounding this topic may not be included in the following table: CPT Code(s) Description Comments 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) 20975 Electrical stimulation to aid bone healing; invasive (operative) 20979 CPT Category III Code(s) No code(s) identified HCPCS Code(s) Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Description Description E0747 Osteogenesis stimulator, electrical, noninvasive, other than spinal applications E0748 Osteogenesis stimulator, electrical, noninvasive, spinal applications E0749 Osteogenesis stimulator, electrical, surgically implanted E0760 Osteogenesis stimulator, low intensity ultrasound, noninvasive ICD 9 Procedure Description Code(s) 78.90 Insertion of bone growth stimulator, unspecified site 78.91 Insertion of bone growth stimulator into scapula, clavicle and thorax (ribs and sternum) 78.92 Insertion of bone growth stimulator into humerus 78.93 Insertion of bone growth stimulator into radius and ulna 78.94 Insertion of bone growth stimulator into carpals and metacarpals Comments Comments Comments
Page: 9 of 15 78.95 Insertion of bone growth stimulator into femur 78.97 Insertion of bone growth stimulator into tibia and fibula 78.98 Insertion of bone growth stimulator into tarsals and metatarsals 78.99 Insertion of bone growth stimulator into other bone 99.86 Transcutaneous (surface) placement of pads or patches for stimulation to aid bone healing Medical Terms Adjunct Something added to another thing but not essential to it. Clavicle Collarbone. Closed Reduction Physical manipulation of a joint or bone externally (without making a surgical excision) to affect a joint relocation or more proper anatomic alignment of broken bone fragments. Colles Fracture Fracture of the lower end of the radius in which the lower fragment is displaced posteriorly. Comorbidities Co existing or additional diseases with reference to an initial diagnosis. Compression Increasing physical pressure on a vital structure. Congenital Pertaining to a condition present at birth, whether inherited or caused by environment, especially the uterine environment. Contusion Injury in which the skin is not broken; a bruise. Diabetes Disease in which the body does not produce or properly use insulin, a substance that is needed to convert sugar, starches, and other food into energy. Diaphysis Shaft of a long bone. Distal Located away from the center of the body.
Page: 10 of 15 Electrode Electrical lead or wire through which current may flow in and out. Electromagnetic Pertains to or produced by magnetism, which is developed by the passage of an electrical current. External On the outside; in this case, on the skin. Extremities Lower or upper limb, such as the leg or arm. Femur Large bone in the thigh that articulates with the pelvis above and the knee below. Fibula Outer and narrower of two bones of the human lower leg, extending from the knee to the ankle. Fracture Broken bone. Fusion Correction of an unstable part of the spine by joining two or more vertebrae. Generator Machine that converts one form of energy into another. Humerus Bone of the upper part of the arm or fore limb. Intramedullary Within the bone marrow. Invasive Involving puncture or incision of the skin or insertion of an instrument or foreign material into the body. Jones Fracture A fracture at the base of the fifth metatarsal. Malignant Usually used interchangeably with the term cancer, but also describes a clinical course that progresses rapidly to death. Metacarpals Five cylindrical bones extending from the wrist to the fingers. Metatarsals Five cylindrical bones extending from the heels to the toes.
Page: 11 of 15 Non Invasive Not breaking the surface of the skin. Oblique Fracture A fracture, the line of which runs obliquely to the axis of the bone. Obliquely Having a slanting or sloping direction. Osteoporosis Reduction in the amount of bone mass, leading to fractures after minimal trauma. Phalanges Finger bones. Pseudoarthrosis Formation of a false joint caused by the failure of the bones to fuse. Radius One of two bones that constitute the forearm. Renal Disease A disorder involving the kidneys. Scaphoid One of the small bones of the wrist, located on the thumb side. Semi Invasive Refers to a minimal breech of the skin. Serial Of, pertaining to, consisting of, or occurring in a series rather than simultaneously. Spinal Fusion Procedure that involves fusing together two or more vertebrae in the spine using either bone grafts or metal rods. Spiral Fracture A fracture, the line of which is helical in the bone. Spondylolysis A defect in the pars interarticularis (a bone connecting one facet joint to another). Static Acting by mere weight without producing motion. Steroid Type of drug used to relieve swelling and inflammation; also all of the natural
Page: 12 of 15 sex hormones are steroids. Stress Fracture Small, incomplete fracture of a bone that occurs without apparent injury as a result of overuse or excessive/repeated stress. Tibia Refers to the long bone between the knee and foot. Transducer Device that transforms one type of energy to another. Ulna One of the two bones that constitute the forearm. Ultrasound Use of high frequency sound waves; may be used in an imaging technique or for therapeutic treatment of soft tissue (or in this case, bone) injuries. Vertebrae Any of the bones or segments composing the spinal column. References American Association of Neurological Surgeons (AANS) Website. American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: bone growth stimulators and lumbar fusion. June 2005. Available at: http://www.aans.org. Accessed December 6, 2011. American College of Foot and Ankle Surgeons (ACFAS) Website. Diagnosis and treatment of forefoot disorders. Section 5. Trauma. 2009. Available at: http://www.acfas.org. Accessed December 6, 2011. Centers for Medicare & Medicaid Services (CMS) Website. National coverage determination (NCD) for osteogenic stimulators (150.2). April 27, 2005. Available at: http://www.cms.hhs.gov. Accessed December 8, 2011. ECRI Institute. Custom Hotline Response (ARCHIVED). Electrical bone growth stimulation for long bones. April 7, 2009. Available at: https://www.ecri.org. Accessed December 1, 2011.
Page: 13 of 15 ECRI Institute. Custom Hotline Response (ARCHIVED). Electrical bone growth stimulation for the wrist, ankle, and short bones. August 18, 2008. Available at: https://www.ecri.org. Accessed December 1, 2011. ECRI Institute. Custom Hotline Response (ARCHIVED). Electrical bone growth stimulation to enhance cervical vertebrae fusion. April 1, 2009. Available at: https://www.ecri.org. Accessed December 1, 2011. ECRI Institute. Custom Hotline Response (ARCHIVED). Ultrasonic bone growth stimulation for fracture healing. August 22, 2008. Available at: https://www.ecri.org. Accessed December 1, 2011. Hayes, Winifred S. Directory Report. Electrical bone growth stimulation, invasive. September 9, 2011. Available at: http://www.hayesinc.com. Accessed December 1, 2011. Hayes, Winifred S. Directory Report. Electrical bone growth stimulation, noninvasive. September 9, 2011. Available at: http://www.hayesinc.com. Accessed December 1, 2011. Hayes, Winifred S. Directory Report. Ultrasound bone growth stimulation. September 26, 2011. Available at: http://www.hayesinc.com. Accessed December 1, 2011. Hayes, Winifred S. Search and Summary. EXOGEN Ultrasound Bone Healing System (Smith & Nephew Inc.) May 20, 2010. Available at: http://www.hayesinc.com. Accessed December 1, 2011. Milliman Care Guidelines 15 th Edition. Bone growth stimulators, electrical, and electromagnetic. Available at: http://cgi.careguidelines.com/login careweb.htm. Accessed December 5, 2011. Milliman Care Guidelines 15 th Edition. Bone growth stimulators, ultrasonic. Available at: http://cgi.careguidelines.com/login careweb.htm. Accessed December 5, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Ankle & foot (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed
Page: 14 of 15 December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Elbow (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Forearm, wrist & hand (acute & chronic), not including carpal tunnel syndrome. 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Hip & pelvis (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Knee & leg (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Low back lumbar & thoracic (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Neck and upper back (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. National Guideline Clearinghouse Website. Work Loss Data Institute (WLDI). Shoulder (acute & chronic). 2011. Available at: http://www.guideline.gov. Accessed December 6, 2011. UpToDate Website. Proximal fifth metatarsal fractures. September 2011. Available at: https://www.uptodate.com/home/index.html. Accessed December 5, 2011. UpToDate Website. Scaphoid fractures. September 2011. Available at: https://www.uptodate.com/home/index.html. Accessed December 5, 2011. UpToDate Website. Subacute and chronic low back pain: surgical treatment.
Page: 15 of 15 September 22, 2011. Available at: https://www.uptodate.com/home/index.html. Accessed December 5, 2011. Washington State Department of Labor & Industries Website. Provider bulletin: bone growth stimulators. August 29, 2009. Available at: http://www.lni.wa.gov. Accessed December 6, 2011.